Inspection on 12/05/06 for Lisnaveane Ltd

This inspection was carried out on 12th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lisnaveane Ltd 28/06/07

Lisnaveane Ltd 07/08/06

Lisnaveane Ltd 17/01/06

Lisnaveane Ltd 19/09/05

Lisnaveane Ltd 12/01/05

Lisnaveane Ltd 14/06/04

Lisnaveane Ltd 16/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lisnaveane 790 Longbridge Road Dagenham Essex RM8 2AA Lead Inspector Ms Rhona Crosse Keu Unannounced Inspection 12th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lisnaveane Address 790 Longbridge Road Dagenham Essex RM8 2AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 592 0022 0208 491 8424 Mr Alfred Henry Gilmore Waddell Mrs Fiona Foo Siang Waddell, Miss Julia Patricia Waddell Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Lisnaveane is a residential property that has been converted and extended over time to provide a care home for 19 older people offering 24 hour care. The home is situated on the corner of a busy road with good transport links. There is parking in the street to the side of the property. There is limited space to the side of the building for parking in the homes grounds. The home comprises of single and shared bedrooms. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection therefore the home did not know the inspector was coming. The inspector arrived at 9.20am the acting manager was not at the home but arrived later. The inspector spoke with service users, staff and the acting manager as part of the inspection process. Service users files and records were inspected and case tracked. The home has been operating at a poor level due to the fact that there is no registered manager. A new acting manager has been employed. The person must put forward an application to register with the Commission. The Commission has met with the providers due to the ongoing concerns about failure to comply with the Care Homes Regulations 2001. As a result of this the Commission have served Statutory Notices on the home. This was in relation to lack of staff training and failing to maintain fire equipment appropriately. The local Fire Authority also served an Enforcement Notice on the home as a result of the home not maintaining the fire equipment. A further Statutory Notice was served by the Commission as the home had not inform the Commission that it had been served with a Prohibition Notice on the passenger lift by Barking and Dagenham Health & Safety Department. At this inspection an Immediate Requirement Notice was served as a result of a fire door not closing. The local Fire Authority was informed of this. What the service does well: From discussion with service users the home appears to take service users choice into consideration (one service user did not rise till around 10am). Others commented on how staff give them a choice in daily life. One service user likes to go out shopping and staff arrange this. Service users spoke highly of staff stating that they care for them well and that nothing is too much trouble. The staff team remain committed to the care of the service users and try to meet their needs as far as possible. A genuine rapport was seen between service users and staff. Relatives were happy with the care provided and had no concerns. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The home has no registered manager. The new acting manager must put forward an application to register with the Commission. The home is not registered to admit service users with dementia. It was of concern that a service user had been admitted into the home with a diagnosis of dementia. This was recorded on the person’s social services assessment. The home inappropriately agreed to this placement, therefore the home is in breach of the registration regulations. Any further failure to operate within the Care Homes Regulations 2001 will result in formal action being taken against the home. The Statement of Purpose and the Service Users Guide require updating with current information. Care plans are not being updated as changes occur and for one service user it was documented that this person has an infection. No care plan was drawn up and no instructions on infection control were written up for staff. The community nurse must be contacted to check if this person is now free from infection. If this is the case then no further action needs to be taken. However if the infection is still present then a care plan specifically for this need must be written up with corresponding infection control instructions for staff to adhere to. Other areas where infection control was poor also need to be addressed. Daily activities need to be improved along with menus that reflect the likes and dislike of service users. The acting manager said that she is to speak with service users to gain their views. Some areas around the home require redecoration and maintenance. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 7 Employment documentation (contracts and induction programmes) need to be put into place. Although the majority of health and safety documentation was up to date and appropriate, the reporting of 2 fire doors not always closing was recorded in the fire book. It is of concern that no action was taken by the providers to ensure that this was dealt with. The Commission served an Immediate Requirement Notice at this inspection due to the lack of action by the providers. The Fire Authority was informed of this failure. The Regulation 26 visit reports that have to be undertaken by the provider and be completed on a monthly basis did not record the concerns about the fire door. The Regulation 26 visit reports must reflect the current situation in the home each month. The new cooker provided to the home is of a domestic type and not suitable for industrial use. The seal is broken, the handle of the cooker is broken and this makes the oven difficult to open. The decorative stainless steel strip at the bottom of the door is bent. When the cooker door is opened it catches on the bottom of the cooker and bends the strip leaving it sticking proud of the door and a danger to staff using the cooker. The cooker must be repaired or replaced The annual quality assurance survey needs to be expanded to social workers and health professionals as well as service users and relatives. Once the information is returned an analysis of the information should be made and this should form part of the Service Users Guide. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Standard 6 does not apply to this home. The outcome group for this area is poor and has significantly more weaknesses than strengths. The lack of a current updated Statement of Purpose does not provide the appropriate information to prospective service users. The home failed to ensure that they appropriately assessed all documentation prior to admitting a service user who is outside the homes registration category. This is poor practice. This reflects on the care that can be provided to the service user as not all staff had received training in dementia care. Contract for service users were held on file. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Statement of Purpose and the Service Users Guide need updating as information is no longer current in this document. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 10 Contracts from social services departments were observed to be held on file. Written pre assessments carried out by the home and social services assessment were also observed. Both were held on service users files. The home is not registered to admit service users with dementia. It was of concern that a service user had been admitted into the home with a diagnosis of dementia. This was recorded on the person’s social services assessment. The home inappropriately agreed to this placement, therefore the home is in breach of the registration regulations. Any further failure to operate within the registration regulations will result in formal action being taken against the home. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The quality outcome area for Standard 7 is poor and has significantly more weaknesses than strengths. Greater care must be taken to ensure the needs of service users are appropriately recorded at all times for the well being of all service users. For standards 8, 9, 10 and 11 the quality outcome areas are good with no significant weakness in these areas. These judgements have been made using available evidence including a visit to the service. EVIDENCE: Care plans are not always being updated. When inspecting records for one service user, it was observed that there had been a diagnosis of an infection. There was no care plan written to ensure that staff followed appropriate infection control procedures. This is poor practice and places both service users and staff at risk. Contact must be made with the community nurse or GP to find out if this infection has now cleared. If the infection has not cleared then a specific care plan must be written up with appropriate infection control information and the specific action to be taken by anyone caring for this person. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 12 Information in relation to health care needs were recorded in most instances with referrals to other health care professionals. The home has a monitoring system to check that medication is being administered, recorded and stored appropriately. The new acting manager had carried out an audit on the 3 May and found that for one service user’s medication had been signed as administered but remained in the monitored dosage system. No other errors in recording were observed. Privacy and dignity were observed to be respected by staff observed caring for service users. Staff attending to personal needs spoke quietly to the service users and assisted them appropriately. In discussion with service users they stated that ‘they look after me well, they help me with my bath I am well cared for’. ‘They treat me nicely when the bath me’ (one member of staff was singled out as being particularly caring). Another service users stated ‘they help me in and out of the bath, I do some things for myself but they treat me well, they treat me with care when they are helping me’. Service users files inspected held information relating to their wishes at the time of death. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The quality outcome area is adequate and has significantly more strengths than weaknesses. Activities must be improved this enhances the fulfilment of service users. Service users should have free access to their rooms at all times choice should not be restricted for staff convenience. These judgements have been made using available evidence including a visit to the service. EVIDENCE: Daily activities are poor. Some of the staff will involve service users in the music playing, but there is no evidence that on a regular basis activities are taking place. The new acting manager has looked at the activities plan and is trying to implement daily activities. Entertainers are brought into the home on a regular basis and service users appeared to enjoy these shows. The next date entertainers are booked to visit the home is the 17 May 2006. Service uses spoken with had varying degrees of satisfaction. One service user stated ‘I like to read, and read all the books that I can’. Another service user was not interested in doing any activities. A further service user stated ‘there’s not much to do but watch Television and sleep’. One service user said ‘ they Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 14 had a party for a service user and a band came and played, we enjoyed that, it’s my birthday soon but I don’t know if they will have anyone to sing at my party, I will be 90 in November’. It was observed that one service user was in bed at the time of the inspection staff stated that the service user rises when they choose. This is seen as good practice. In discussion with service users they confirmed that they can rise and go to bed when they choose. One service uses stated ‘the girls help me to get up washed and dressed, they ask me what I want to wear, they get things out of the wardrobe for me to choose’. Another service users said ‘I can go to my room when I want and can do what I want’. One service user’s bedroom door was observed to be locked by staff. The service user wandered backwards and forwards unable to gain access. The staff stated that the person was not allowed to go into the room although no clear information as to why this was could be given. All service users should have free access to use their rooms at any time. The home places no restrictions on visiting times and relatives were seen to come and go during the inspection. The two relatives visiting at the time of inspection said that they had no concerns about the care of their relatives and did not want to raise anything with the inspector. A service user stated ‘my relatives visit me at different times’ they can come at any time and they are treated well they are always made to feel welcome’. The menu was said not to reflect the meals being provided, this was in relation to the food being purchased by the providers. The acting manager stated that menus were to be discussed with services users, this was something that she wanted to implement as soon as possible. Service users spoken with said ‘I like the meals the food is nice’. Another service user said ‘I get enough to eat, you can have more if you want’. If you don’t like something they will do something else, they can’t do much more than that’. During the afternoon a staff member was seen asking service users what their choice for the tea time meal was. At lunch time 5 service users had fish and chips and one service user had mashed potato instead of chips. 5 other service users had egg and chips. The pudding was ice cream and peaches. Records were kept of all meal choices. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The outcome group is adequate and has significantly more strengths than weaknesses. Service users and relatives were happy with the care, no complaints were recorded. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The home has a policy and procedure for dealing with any complaints received. The information held identifies the CSCI and provides the address and telephone number of the Commission. A record is kept of any complaints received. There had been no complaints recorded since the last inspection. The Commission had received an anonymous complaint. This complaint was passed back to the provider to investigate. A written response to the complaint is required to be sent to the Commission. Service users spoken with said ‘I have no complaints’. Another service user stated ‘I am happy here I have no complaints’ ‘ I get on well with everyone, I like Fiona’. Relatives visiting at the time of the inspection did not want to speak to the inspector stating ‘We have no complaints’. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The quality outcome area is adequate as there are some strength but areas of particular weakness. Poor infection control places service users at risk. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The fence to the front of the garden has been repaired and re-stained. Work is being undertaken to the garden to create a flower bed in the centre of the lawn. The home has tables and chairs for service users to sit out on the patio when the weather is good. One service user was sitting in the garden. The premises were inspected and it was observed that the home was clean and tidy. One bedroom, room 23 was found to have an odour of stale urine. The carpet requires cleaning more often to remove the odour. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 17 None of the bedroom doors have appropriate locks. The proprietors must fit suitable locks to all occupied bedrooms that can be opened with a key from the outside and a turn knob from the inside. A master key system should be used. Service users are able to bring small pieces of furniture and this was in evidence in the bedrooms. Rooms were very personalised. Aids and adaptations are provided for service users in bathrooms. Any specialist equipment is provided in conjunction with the community nurse as this is a care home that does not provide nursing care. The laundry was inspected. At the last inspection in March 2006 it was observed that dirty water from the washing machines was running over the garden and not going down the drains, due to the drain pipe being broken. This has now been repaired. Infection control was poor in the laundry room as tabards used to protect the clothing of service user whilst eating were put into laundry baskets with soiled underwear. This is poor practice. At the last inspection it was observed that no toilets or bathrooms had soap or towels to enable anyone using the toilet to wash their hands. At this inspection (the domestic work was completed) there was no soap in toilets identified as 1, 7, 12, 14, 20, 25. Two bathrooms had no soap and towels to enable anyone to wash their hands. The home must provide this. As the home has several vacant bedrooms the home should seek advice from the Environmental Health Officer about the possibility of Legionella building up in the pipe work of the vacant bedrooms. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality outcome in this area is adequate as there are some strength but areas of particular weakness. All documentation relating to employment including appropriate contracts for staff and staff development and training should be addressed to ensure staff undertake the training required to meet the needs of service users. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were appropriate at the time of the inspection for the needs of the current service users. Staff files inspected held appropriate employment documentation. Contracts of some staff were blank or they had contracts that related to past providers who owned the home. The proprietors must have copies of completed contracts held on file that are Lisnaveane House contracts and remove any old contract that do not relate to the current employers. Staff working between the two homes Lisnaveane Lodge and Lisnaveane House must have copies of employment files held in each home and these must be available for inspection. There are no training and development plans for staff. Staff are receiving formal supervision and the staff files inspected evidenced that all had received Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 19 at least one supervision session. As part of formal supervision the manager must identify the training undertaken and any training still required, setting up a training and development plan in line with the needs and aspirations of staff. It is recommended that a supervision chart be drawn up to identify when staff have received formal supervision. Both the supervisor and the supervisee should date and sign the chart when supervision has taken place. This will evidence more easily supervision that has taken place and also show at a glance if staff have received the minimum of 6 supervision sessions in any one ‘rolling’ year. Three files held annual appraisals of staff performance. Staff files held information relating to the training they had undertaken. Medication training took place in January. 31 of the staff team have undertaken NVQ level 2 training and now have this qualification. The remainder of the staff are taking NVQ level 2 and should complete this in June 2006 making 50 of the staff team qualified to NVQ level 2. Staff training recently undertaken is manual handling on the 18/4/06, basic first aid 6/4/06 and food hygiene on the 26/3/06. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality outcome area is poor as important National Minimum Standards are not being met in this section. There is no registered manager and the home has been without a manager who has completed the registration process for some time. The providers did not take appropriate action to ensure the fire doors close appropriately this places service users at risk. The regulation 26 visit reports written by the provider do not reflect the true operation of the home. These judgements have been made using available evidence including a visit to the service. EVIDENCE: The home has no registered manager and the home is not operating appropriately due to this. The new acting manager must put forward an application to register with the Commission. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 21 The new acting manager is going to implement the key worker system as this was not working as it should be. The acting manager has held 2 staff meetings these took place on the 5/5/05 and the 6/5/06. A new system of communication has been introduced with each team having a communication book to ensure messages are left for the appropriate staff to deal with. One staff file inspected did not have a completed induction programme the documentation was blank. All new staff employed must undertake a written induction programme. This induction programme must be signed by both the supervisor carrying out the induction and the new staff member. Several areas require attention within the building. Bedroom 8 requires decorating both the walls and woodwork. There is a large crack in the wall of bedroom 27 this requires repair and decoration made good afterwards. The balcony requires painting and the armoured cable needs securing to the wall. The carpet in bedroom 23 requires shampooing to remove the odour of stale urine. This may need to be carried out on a daily basis to ensure good odour control. The bedrooms do not have appropriate locks fitted to them. These should be provided with a lock that is opened from the outside with a key and opened from the inside with a twist knob. The system must have a master key to allow entry in an emergency. Staff had recorded as part of their weekly fire call point checks that a door numbered as fire door 4 was not closing and the kitchen door in zone 1 was also reported as not closing appropriately. This was recorded in the fire book on two occasions on the 11/4/06 and the 24/4/06. The inspector went to the door identified as fire door 4. When the magnet was released holding the fire door the door did not swing to a close and stayed open. It was observed that the chain to close the door had been removed from the door. Although this had been reported in the fire book the provider had not taken any action to rectify this. As a result of this the home was served with an Immediate Requirement Notice. The local Fire Authority were contacted by the inspector as a result of this failure by the providers to take the appropriate action to ensure the fire door closed appropriately. The provider is required to make a visit and complete a written report on the findings of the visit on a monthly basis. However these visits and reports made no mention that there was any concern about the fire doors (zone 2, door number 4 or the kitchen door in zone 1) not closing. The provider is therefore not monitoring the operation of the home appropriately as this was recorded by staff in the fire book. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 22 The home holds no money for service users. Any items purchased or services provided, hairdresser or chiropody is paid for by the home and invoiced to the relatives. All other health and safety documentation was found to be in order. The cooker in the kitchen is broken and requires urgent repair or replacement. The seal around the glass on the door has come loose and is no longer sealing the heat in the cooker. The oven door handle (which is the length of the cooker) is broken. Staff are having to open a heavy door using a broken piece of handle. The stainless steel decorative edging to the cooker door has come unstuck and is being bent each time the door is opened. This strip of stainless steel poses a danger to staff’s legs using the cooker. The cooker is not of an industrial type and is only suitable for a domestic premises. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 3 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x x 3 x 1 Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4&5 Requirement The Statement of Purpose and the Service Users Guide must be updated to reflect the current situation in the home. The home must not admit service users outside their registration category. Care plans must be updated as service users needs change. This is a restated requirement from the last inspection. A care plan should be written up for each identified need of a service user (infection control in relation to service user identified to the manager if the infection is still present). All medication must be recorded and administered in line with prescribing instructions. This is a restated requirement from the last inspection. Daily activities must be improved. Choice should not be restricted (service users should have access to their bedrooms at any DS0000027906.V294526.R02.S.doc Timescale for action 30/06/06 2 3 OP3 OP7 14(1)(a) 15(1) & (2) 30/06/06 30/06/06 4 OP7 15(1) & (2) 30/06/06 5 OP9 13(2) 30/06/06 6 7 OP12 OP14 16(2)(n) 12(3) 30/07/06 30/06/06 Lisnaveane Version 5.1 Page 25 8 OP15 12(3) & 16(2)(1) 23(2)(d) 23(2)(b) & 23(2)(d) 23(2)(b) & 23(2)(d) 16(2)(k) 9 10 11 12 OP19 OP19 OP19 OP24 time). Review the menus, (menus must reflect the meals provided). Discuss with service users their choice of meals. Decorate bedroom 8 walls and woodwork. Repair the crack in the wall in bedroom 27 and make good to the decoration. Decorate the balcony and secure the armoured cable to the wall Shampoo the carpet in bedroom 23 to remove the odour of stale urine. This may need to be carried out daily. Provide appropriate locks that are operable from the outside with a key and can be opened with a twist knob from inside the room. There must be a master key system. Tabards used at meal times must not be put into the laundry baskets among fouled clothing/linen. Seek advice from the Environmental health officer about the water lying in pipe work in vacant rooms and the risk of Legionella due to this Soap and towels must be provided in all W.C.’s and bathrooms. This is a restated requirement from the last inspection. Contracts must be completed for all staff (contracts relating to past owners of the home are no longer legal documents). Lisnaveane House must provide appropriate contracts for staff. Any staff working at Lisnaveane House must have a copy of all employment documentation held at the home. This must be DS0000027906.V294526.R02.S.doc 30/06/06 30/07/06 30/06/06 30/07/06 30/05/06 13 OP24 12(4) 30/08/06 14 OP26 13(3) 13/05/06 15 OP26 13(3) 30/05/06 16 OP26 13(3) 30/05/06 17 OP29 17(2) schedule 4(f) 30/06/06 18 OP29 17(2) schedule 4(f) 30/06/06 Lisnaveane Version 5.1 Page 26 19 OP30 18(1)(a) 20 OP31 9 available for inspection at any time. (staff member came from Lisnaveane Lodge). All staff must have a training and 30/07/06 development plan drawn up. This is a restated requirement from the last inspection. The home must put forward a 30/05/06 manager for registration with the Commission who is suitably qualified as identified in the Care Homes Regulations 2001 & National Minimum Standards. This is a restated requirement from the last inspection. The home is not being run in the best interests of the service users. Requirements set at inspections must be complied with to ensure the health and wellbeing of service users. Regulation 26 visit reports must reflect the true operation of the home. A quality assurance system must be in place. A new quality assurance questionnaire must be sent to all service users relatives social workers and health professionals. The home must ensure that the fire alarm system is in working order at all times. Repairs/replacements must be carried out without delays. An Immediate Requirement Notice was served as a result of this. Referral has been made to the Fire Authority. The homes cooker is not suitable for use. This must be urgently repaired or replaced. All staff must have a completed induction programme. Remove wooden planks stored in DS0000027906.V294526.R02.S.doc 21 OP33 24(1)(a) 30/06/06 22 OP33 24(1)(a) & (b) 30/08/06 23 OP38 23(4)(c)(i v) 12/05/06 24 25 26 OP38 OP38 OP38 23(2)(c) 18(1)(a) 13(4)(c) 30/06/06 30/06/06 12/05/06 Page 27 Lisnaveane Version 5.1 the garden where the fire door opens as this restricts the escape route out of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP36 Good Practice Recommendations Draw up a supervision chart for a ‘rolling year’. Both the supervisor and the supervisee should date and sign the chart when the formal written supervision session has taken place. Lisnaveane DS0000027906.V294526.R02.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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